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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490103579
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:30:07 PM


Document Has Been Signed on 01/25/2023 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WOODSIDE WEST SCHOOLFACILITY NUMBER:
490103579
ADMINISTRATOR:DUMBADSE, DIANAFACILITY TYPE:
850
ADDRESS:2577 GUERNEVILLE ROADTELEPHONE:
(707) 528-6666
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:70CENSUS: 40DATE:
01/25/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Diana DumbadseTIME COMPLETED:
12:34 PM
NARRATIVE
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On 01/25/23, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Director, Diana Dumbadse (D1). The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucet tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site "G", a sink in currently vacant classroom #5, had a reading of 9.2 (ppb). D1 stated that room #5 as not been in use for the last 5 years. All other sources of water tested below the allowable level of 5.0 ppb.

On 01/12/23 LPA notified D1 by phone of the action level exceedance (ALE) of sample site, “G” and emailed D1 a copy of the lead testing results from the California State Water Resource Control Board. LPA informed D1 that she will need to immediately make sink “G” inaccessible to children and post the test results at the facility within 24 hours. In an email to D1, LPA requested that D1 submit photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999) no later than one week from the date of the ALE notification. A photo documenting the sink as inaccessible was received by on 01/13/23. LPA received photos of all water faucets tested on 1/23/23. D1 stated children in care are receiving drinking water from individual water bottles from home that staff refill from sink faucets inside the facility as needed (excluding sink "G"). If a child does not have their water bottle, a disposable cup of water is provided.

On 12/07/22 D1 submitted by email the following required documents after testing had been completed; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999). During today’s visit, LPA verified that the test results were posted and that Sample site “B” was made inaccessible to children in care.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Director, Diana Dumbadse.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2023 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WOODSIDE WEST SCHOOL
FACILITY NUMBER: 490103579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2023
Section Cited

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101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.



This requirement was not met as evidenced by:
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LPA observed that the facility has temporarily removed the affected faucet “G” from service by way of a sign and caution tape. D1 stated that the facility plans to replace faucet “G”, flush and retest, submitting results to LPA Strother by 2/25/23. amy.strohter@dss.ca.gov. D1 stated that families have been informed of the ALE by way of posting results.
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Based on record review, the facility had one faucet (Site “G”) that exceeded that allowable levels of lead in the water (9.2 ppb). This is a potential health and safety risk to children in care.
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D1 stated she will send out a text to all families to notify them of the plans to remediate and mention how children will continue to receive drinking water from water bottles from home, refilled as needed from faucets that tested with acceptable levels.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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